[What is overdiagnosis?] / Överdiagnostik ­ vad är det?

A considerable amount of spending in health care is deemed wasteful. Overdiagnosis, i.e. the labelling of a person with a diagnosis that lacks net benefit, is an entity within the overarching concept of ¼too much medicine«. Overdiagnosis includes overdetection and overdefinition. Disease mongering is a type of overdefinition with economic drivers. Overtesting and overtreatment are other aspects of ¼too much medicine«, but are not overdiagnosis per se. Medical research tends to focus on benefits of diagnostics and therapy, whereas overdiagnosis and other harms receive less attention, leading to overestimation of benefits. The international network Choosing Wisely has been successful in changing the diagnostic mindset in several countries and a Swedish campaign is under way, yielding new possibilities to counteract ¼too much medicine« and the specific problem of overdiagnosis.

[Choosing Wisely in Sweden]. / Kloka kliniska val ­ att avstå det som inte gör nytta för patienten.

Overdiagnosis and overtreatment receive increasing attention. More than 20 percent of health expenditure is without patient benefit, so-called low-value care. Several national and international initiatives have been launched to minimize low-value care. Arguably, the most widely spread initiative is Choosing Wisely. First launched by the American Board of Internal Medicine in 2012, this campaign has spread to more than 20 countries. The Swedish Society of Medicine has identified low-value care as a significant problem in Swedish health care and  has established a working group to investigate if and how a campaign based on Choosing Wisely would be feasible in Sweden. Here, the working group reports on the history of Choosing Wisely, identifies potential challenges for deimplementation generally and in the Swedish context specifically.

Dealing with being prescribed cardiovascular preventive medication: a narrative analysis of qualitative interviews with patients with recent acute coronary heart disease in Sweden.

OBJECTIVE: To explore how patients with experience of acute coronary heart disease make sense of, and deal with, the fact of being prescribed cardiovascular preventive medication. DESIGN: Qualitative interview study. SETTING: Swedish primary care. PARTICIPANTS: Twenty-one participants with experience of being prescribed cardiovascular preventive medication, recruited from a randomised controlled study of problem-based learning for self-care for coronary heart disease. METHODS: The participants were interviewed individually 6-12 months after their hospitalisation for acute coronary disease. A narrative analysis was conducted of their accounts of being prescribed cardiovascular preventive medication. RESULTS: Four themes shape the patients' experiences: 'A matter of living' concerns an awareness of the will to live linked to being prescribed cardiovascular preventive medication regarded in the light of the recent hospitalisation. In 'Reconciliation of conflicting self-images', patients dealt with being prescribed preventive medication through work to restore an identity of someone responsible in spite of viewing the taking of medication as questionable. The status of feeling healthy, while being someone in need of medication, also constituted conflicting self-images. Following this, taking medication was framed as necessary, not as an active choice. 'Being in the hands of expertise' is about the seeking of an answer from a reliable prescriber to the question: 'Is this medication really necessary for me?' Existential labour was done to establish that the practice of taking cardiovascular preventive medication was an inevitable necessity, rather than an active choice. 'Taking medicines no longer a big deal' could be the resulting experience of this process. CONCLUSIONS: Unmet existential needs when being prescribed cardiovascular preventive medication seem to be a component of the burden of treatment. A continuous and trustful relationship with the prescribing doctor may facilitate the reconciliation of conflicting self-images, and support patients in their efforts to incorporate their medicines taking into daily life.

Patient participation in decision-making about cardiovascular preventive drugs - resistance as agency.

OBJECTIVE: The aim of the study was to describe and explore patient agency through resistance in decision-making about cardiovascular preventive drugs in primary care. DESIGN: Six general practitioners from the southeast of Sweden audiorecorded 80 consultations. From these, 28 consultations with proposals from GPs for cardiovascular preventive drug treatments were chosen for theme-oriented discourse analysis. RESULTS: The study shows how patients participate in decision-making about cardiovascular preventive drug treatments through resistance in response to treatment proposals. Passive modes of resistance were withheld responses and minimal unmarked acknowledgements. Active modes were to ask questions, contest the address of an inclusive we, present an identity as a non-drugtaker, disclose non-adherence to drug treatments, and to present counterproposals. The active forms were also found in anticipation to treatment proposals from the GPs. Patients and GPs sometimes displayed mutual renouncement of responsibility for decision-making. The decision-making process appeared to expand both beyond a particular phase in the consultations and beyond the single consultation. CONCLUSIONS: The recognition of active and passive resistance from patients as one way of exerting agency may prove valuable when working for patient participation in clinical practice, education and research about patient-doctor communication about cardiovascular preventive medication. We propose particular attentiveness to patient agency through anticipatory resistance, patients' disclosures of non-adherence and presentations of themselves as non-drugtakers. The expansion of the decision-making process beyond single encounters points to the importance of continuity of care. KEY POINTS Guidelines recommend shared decision-making about cardiovascular preventive treatment. We need an understanding of how this is accomplished in actual consultations.This paper describes how patient agency in decision-making is displayed through different forms of resistance to treatment proposals. •The decision-making process expands beyond particular phases in consultations and beyond single encounters, implying the importance of continuity of care. •Attentiveness to patient participation through resistance in treatment negotiations is warranted in clinical practice, research and education about prescribing communication.

Clinical Gaze in Risk-Factor Haze: Swedish GPs' Perceptions of Prescribing Cardiovascular Preventive Drugs.

Aims. To explore general practitioners' (GPs') descriptions of their thoughts and action when prescribing cardiovascular preventive drugs. Methods. Qualitative content analysis of transcribed group interviews with 14 participants from two primary health care centres in the southeast of Sweden. Results. GPs' prescribing of cardiovascular preventive drugs, from their own descriptions, involved "the patient as calculated" and "the inclination to prescribe," which were negotiated in the interaction with "the patient in front of me." In situations with high cardiovascular risk, the GPs reported a tendency to adopt a directive consultation style. In situations with low cardiovascular risk and great uncertainty about the net benefit of preventive drugs, the GPs described a preference for an informed patient choice. Conclusions. Our findings suggest that GPs mainly involve patients at low and uncertain risk of cardiovascular disease in treatment decisions, whereas patient involvement tends to decrease when GPs judge the cardiovascular risk as high. Our findings may serve as a memento for clinicians, and we suggest them to be considered in training in communication skills.